Tenants Online Quote - HO-4

Please complete the following and press submit or call 800-396-6226 x107 for an instant phone quote

Agent Information:
Commonwealth Underwriters Agent Code:	Note: this field is optional

Agency Name:
Agent Name:
Agent Phone:
Agent Email:	(A copy of the quote will be sent to this address)

Insured Information:
Insured Name:
Insured Email:	(will only be used to communicate regarding this account)
Insured Phone Number:
Occupation:
Employer:
Date of Birth:	//
Is there an additional resident or spouse?
Additional Resident's Name:
Additional Resident's Occupation:
Additional Resident's Employer:
Additional Resident's Date of Birth:	//
Dwelling Address:
,
Dwelling Zip

Is the Mailing Address the same as the Dwelling Address?
Mailing Address
,
Location Zip

Effective Date
Proposed Effective Date

Dwelling:
Protection Class:*
	* If you do not choose a protection class, your quote is not valid and cannot be honored by Commonwealth Underwriters.
Year Built:
Dwelling Area (sq. footage):	sq. ft.
Number of Stories:
Is Dwelling in Good Condition?
Does Dwelling Have any Existing Damage?
Is Dwelling Undergoing any Renovation or Construction?
Type of Construction:

Applicant:
Please choose one of the following to describe insured's credit history:
Is the applicant a student?
Has the Applicant had any Conviction of Arson or Fraud Related to any loss on Property or Insurance?
Has there been a Bankruptcy Within the Last Year?
Has there been a Repossession in the last 3 years?
Any past due Child Support?

Insurance History:
Has there been any Prior Insurance on this Account?
Please input name of Prior Carrier:
Expiration Date of Previous/Current Insurance?:
Prior Policy Premium:
Risk New to Agency?
Was Policy Terminated at Companies' Request?
Has there been a Lapse of Coverage over 30 Days?
What was the Reason for Termination?
	* Please provide an explanation in the Additional Comments section at the bottom of the page

Loss History:

Any Open Claims?
Number of Losses in the Last Five Years:
	If none, enter 0

	Date (mm\|yyyy)	Type of Loss	Details	Amount Paid
1)				$
2)				$
3)				$
4)				$
5)				$

Coverages:
Value of Contents?*	$
	$20,000 minimum value is included with the policy. Increase value if more coverage is required.
Limit of Liability:	$100,000 Included
Increased Cov. D?:
	Coverage D defaults to 10% of the Value of Contents.

Optional Coverages:
Replacement Cost Personal Property

Financing:
Would you like a Finance Quote?	(Click if Yes)
Agency Address
Agency City
Agency State
Agency Zip

Commission
What commission would you like for this account?

Any Additional Comments:

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For higher limits or coverage options not listed, please contact Laura Fraley, Ext 107.

Any questions or problems with the form? Please contact Laura Fraley

Only Commonwealth Underwriters, Ltd. has binding authority. Coverage will not be bound until application has been received, reviewed, and accepted by Commonwealth Underwriters, Ltd.

Phone:	804-359-4568
Toll Free:	800-396-6226
Fax:	804-359-6994
E-Mail:	info@commund.com